Strategic partner updates for September 2013

03 October 2013

Health and Social Care update from our work as Strategic Partner to the Department of Health, NHS England and Public Health England

This month’s update includes a report from the latest Strategic Partners meeting, reflections on Disability Rights UK’s workplan and on how this will support local user-led membership organisations and finally news and insights on Healthwatch England, Commissioning Skills at NHS England, user involvement at the Care Quality Commission (CQC) and further programmes such as support for organisations developing a social impact bond.

Where is Disability Rights UK with its workplan as a strategic partner and how does this help our members and networks?

If a thing or two have changed in the last few decades, then it is greater awareness that people who use services have become partners in social care and health and are co-producers of health outcomes. The more someone is involved in social care and health the greater are his or her prospects for positive health outcomes. There is also a shift towards outcomes-based commissioning and away from NHS providers simply delivering activities for their payments. Yet, who defines these outcomes? How can we move away from pure assumptions of ‘what makes people feel better’ and instead ask people directly and work with them from start to finish? The Friends and Family Test can only form the beginning.

Commissioning needs not only to listen but to respond to people throughout the commissioning cycle rather than coming up with ready-made solutions run by a few select providers. Commissioning resources need to be tied in with community support. To this end, people must be engaged and seen and encouraged to exercise choices and pursue their own 'care pathways', and the professional’s role must be to pick up on that context and not vice versa. Building on ‘lived experience’ means supporting people to increasingly tap into their own informal support networks and those of their peers while choosing less intensive care and treatment options. Many Adult Social Care departments and Clinical Commissioning Groups do grasp the issues but do not know where to start. If one looks at mental health for example, important questions are ‘how can people be supported not to rely on ready-made services and empowered to make choices for themselves?’ ‘How can services pave the way for such empowerment to support people in sometimes difficult transitions from set service interventions to more innovative peer support?’ What are fair, comprehensive and viable transitions from block to spot contracts with a minimum of necessary double running costs?

Personal (health) budgets that can be pooled between people are key to all this transformation. ‘Pooling’ offers creative ways to build collective insights and empower the individual at every single turn even across more complex care pathways. Care and treatment must then align with and build on people’s own systems of self-directed support, eg in hospital admissions and at discharge. How come that we expect and do not question the existence of services that focus on ’re-ablement’ no matter how effective they are? Why is there almost consensus to ‘disable’ people beforehand just because self-directed support typically ends at the hospital entrance? If there is great empowerment, there would be no need for re-ablement. Take the example of Care Quality Commission inspections collecting data on how ‘caring’ and ‘responsive’ services are. It is great if items for data collection are co-produced with those who experience directly how ‘caring’ and ‘responsive’ services are. However, if people would be empowered to explore for themselves and make up their mind and to talk to each other and then to exchange views on the support they are experiencing, their peers could – over time - learn more to directly build on their recommendations when making choices between different types of support. Safeguarding should primarily have such a basis of empowering people to do things for themselves rather than having everything laid out for them. Who of the readers would deny that right for themselves? How can we be so ready to deny people that right who are vulnerable or have learning disabilities? Should our role not be to ensure that utmost support is given so that there is an equal level of choice and control?

Are we not all NHS patients and should therefore all have the same say? The supported choices under (pooled) personal budgets should be incorporated into mainstream commissioning plans and made available to everyone with health and social care needs. Alongside personal budgets, there should also be wider partnerships to influence, co-produce and shape positive health outcomes and improve independent living and quality of life (alongside integration and productivity gains). Such transformation needs a shared sense of what it is important to achieve and how to go about it between people who commission and use services. Lived experience is an enabler and not a barrier in this process. Those who do not have ill-health, injuries and (long-term) disability need to open up and understand those who do. Then new community initiatives can be set out and relevant and agreed and have real impact on people’s and whole communities’ health outcomes. If only enough people with ‘lived experience’ and seldom heard people can be engaged, then nothing stands in the way of community development that benefits everyone further down the line, where local needs, assets, preferences, aspirations, insights are all part of the mix to set priorities with the help of established methods such as ‘Working Together For Change’ and ‘Citizens Juries’ for example.

For the time being, there are deeply routed cultural barriers to personalisation and choice and control in social care and NHS – despite the case that positive health outcomes go back to lots of variables that are in the control of the person and not just social care and clinical procedures. The Francis report on the failings at Mid Staffordshire and the Winterbourne View reports have drawn our attention to the absence of people’s voice and peer support but there are not many suggestions for positive ways forward. So how can we bring on a hands-on devolution of power to people, stop all rhetoric and upscale such innovation at the same time?

Our programme ‘user-driven commissioning’ has built on three stepping stones: Firstly, some people were supported to pool their personal budgets so that they could pursue shared interests - often for the first time in their lives. Secondly, a few projects went further and used the insights gained from the process to directly inform de- and re-commissioning. Thirdly, there were projects, which were most keen to develop peer support as a way of shaping the market and did so through user-led provider organisations (ULOs). As a result, a range of personal budget ‘pooling’ projects have begun to shift away from block contracts and put quality on a more equal footing with price within service level agreements, with peer support becoming a defined element to assess, specify and co-deliver improved access and discharge pathways in mental health for example. One ULO has been kick started by a charity provider consortium to provide peer support across care areas and to also quality check its provider funders. Now we are working on a replicable user led commissioning approach for people with personal budgets and 'franchise' spread model.

Disability Rights UK, Shaping Our Lives and Change have made some further proposals and started working with Department of Health, Public Health England and NHS England, eg Patient Information Directorate and Commissioning Skills team. We also need your support with some of these proposals. These are the some of the areas we are exploring with partners:

Could there be a ‘right to peer support’ at diagnosis and crisis stages, meaning an automatic process by default to refer people to a peer who has travelled a similar path in the past and can share experiences? Process should be triggered at both GP level and nationally via Choose & Book, e-referral systems. This would bring different (treatment or support) options to life first-hand. There will be a need to build up and coordinate local bases of peers, patient leaders, etc.. – a substantial role for disabled peoples’ user-led organisations and patient groups.

Can we create new payments profiles that are linked to NHS providers achieving minimum scores on user quality ratings and patient-reported outcome/experience measures? Comprehensive measures would capture (changes in): service use (ease/speed of referrals, stepping up/down), social capital, employment, choice and control. This would create outwards accountability and radically improve the dynamics between services and people who use them. It is a learning process, and so at first we need to remove the gradient between staff and patients. Both patients and staff need to have access to similar training budgets to equip them for their role in assessing outcomes and experiences.

Enhancing access to good quality information for people across all protected characteristics, eg appointments via email, support via helplines as an alternative to digitalisation.

We are looking for charity providers to support them to help establish independent user-led organisations. Providers can kick-start peer support, and it is in their own interest. One such offspring is the ULO ‘Peer Support North East’ which not only sees 350 of their peers a month to support them across traditional service boundaries but also checks the services of its founders for quality and produces health audits: For the founder charity consortium, its long-term investment in peer support means building a feedback mechanism into their own services. As a result, providers will be better prepared for the demands of more personalised and flexible solutions from service users. Finally, providers can improve on efficiency as bottlenecks in the system are more easily spotted and more readily rectified. We are keen to spread this model as widely as possible and support charities and user projects in the process. With the National Housing Federation we have started a project to map and improve how handyperson services can be taken over by residents and how such enterprises can be joined up with wider community development. Please get in touch with Bernd.Sass@disabilityrightsuk.org if you can help us reach out to local provider charities. We can also provide you with some tweets to link to our project.

The Strategic Partners last met on 17 September 2013:

SPs Race Equality Foundation and National Housing Federation are doing work on the implications of ‘Housing and Health/Healthy Places’. There will be an event in January 2014. After that a short briefing will be provided. SP UK Health Forum will deliver a further event on ‘fuel poverty’. A toolkit will be made available with the possibility to add case studies etc.. A group of SP s including Disability Rights UK met up to coordinate their activities and make a case for ‘Building Community Capacity to improve Public Health and Care Outcomes’ – we believe that personalisation and longterm investment in people and their own support networks will be key to this.

Healthwatch England (HWE) delivered a presentation on their purpose and approach. They have a £3m budget and about 30 staff to exercise statutory power to hold Monitor, CQC and Clinical Commissioning Groups (CCGs) to account. Conversely, local Healthwatch (HW) organisations have a ‘duty to share information’ with HWE. However, local HW are commissioned by the local authority (LA) and so are not overseen by HWE. HWE’s role rather is to provide support. Disability Rights UK and HWE plan to do some work on informing local HW about and promoting user-driven commissioning as a community approach to capacity building. So how does this mutual overseeing work in practice? For instance, if there are variations in terms of how well HW are engaging with seldom heard groups, HW England can ask LAs why engagement isn’t happening. As the local HW is accountable to the LA, they can request improvements. In turn, the LA has a statutory requirement to report to HW England.

The Strategic Partners Programme is currently under review. As part of this a survey is undertaken and an internal audit with PriceWaterhouseCooper. SPs have been reassured that the key aims of the programme are around improving engagement with and reaching out to equality and seldom heard groups. A new SP will be recruited to focus on work and ‘worklessness and health’ in particular. Disability Rights UK have long been asking for a cross-governmental response to cover for instance the consequences that the policies of the Department of Work and Pensions are having on people’s health outcomes.

Public Health England (PHE) delivered an update: the two biggest health issues are muscular skeletal and low level mental health problems. The highest risk factor is tobacco, followed by high blood pressure followed by dietary issues. The Marmot Report shows high numbers of people who will have disabilities before retirement. The Wanless report shows a correlation between health outcomes and the extent to which people have been engaged with their health beforehand. PHE are developing a strategy for describing the state of the nation’s health and what the main drivers are to improve this. They want to be able to integrate this with local Joint Strategic Needs Assessments (JSNA) to create a forecast for health. There is also an interest at PHE to build evidence that one can make improvements for their own (and others’) health and a tool for tracking progress. The focus is not on improving health services but improving people’s health by getting people engaged in their own health.

CQC gave an ‘involvement update’. They have now appointed a Chief Inspector of Hospitals and GPs. There will be new acute inspections of hospitals and public listening events will be held. They will change how they inspect mental health services and undertake a Dementia Care review in December / January. Children’s inspections continue to take place. CQC are keen to create a Peoples Panel to review plans. CQC are talking to some SPs about a programme of work for 2-3 years. This includes Disability Rights UK who are supposed to explore and shape with local members and networks the meanings of ‘caring’ and ‘responsive’ services.

The Innovation Excellence and Strategic Development Fund of the Department of Health (IESD) has set deadlines for applications by 11th October and 25th October. Last year 45 of 300 applications were funded. The strategic development strand has been strengthened. It can make up to 25% of the applicant’s turnover.

Monitor conducts a GP Survey in 8,000 GP practices following its role to protect and promote the interest of patients. This will explore governance, set prices, integrated services, fair competition. The survey will focus on: 1. Patients ability to access services, 2. What is stopping practices from expanding or new practices opening? and 3. New ways of working. Asked for the value of this, it was pointed out that NHS England needs to understand the market for GPs and what the challenges are. Monitor cannot deal with micro issues but they can deal with broader policy and practice such as difficulties making appointments, apparent closed lists, etc..

The Department of Health, Public Health England, NHS England and Strategic Partners invite colleagues to join a FREE learning event for the Sector on Mental Health and Wellbeing. The programme is being developed by the Mental Health Providers Forum in partnership with DH, PHE and NHS England.

As understanding and community awareness grows about the fact that 1 in 4 people experience at some point in their lives debilitating mental ill health, greater importance is being placed on good mental health. The organisers hope to use this learning event to break down any remaining myths and stigma surrounding mental illness, and to discuss mental health as an important and equal component in whole person care and wellbeing. They also want to address the importance of further development and growth in innovation for the not for profit sector, in order to meet an array of needs, as people are actively moving away from secondary care support into less formal and more community focussed service settings…

As well as some key updates on national mental health developments, your input through world café sessions will help shape the way that we can all work together more cohesively, to create more person centred practice. To register for this event please click on: https://www.eventbrite.co.uk/event/8385464149

The Health and Social Care Act 2012 places duties on clinical commissioning groups (CCGs) and NHS commissioners, around the participation of patients in decisions about their own care and supporting the participation of local communities in decision-making. The aim in producing Transforming Participation in Health and Care is primarily to showcase the range of options which commissioners can use to ensure that patients can be active in their own healthcare and to ensure that the services they commission meet the wants and needs of the local population including tools, resources and suggested action plans. We recognise and support the fact that commissioners, through the different options, can – and should – tailor their approach to the individuals and groups within their populations and hope that the guidance will stimulate discussion about how CCGs and all NHS commissioners can develop their own strategies.

Patients tell 7-day service forum: “Be ambitious and not constrained by the past”

NHS England’s national medical director, Professor Sir Bruce Keogh, has warned patients and health care professionals the introduction of seven day services will be “difficult and radical.” There are firm plans to open NHS services for seven days a week which will require vast coordination.

This Code has been developed by the provider sector as a response to Winterbourne View. Providers and Commissioners are being invited to sign up to the Code to drive up quality and be open and transparent about what they are doing to meet it. http://www.drivingupquality.org.uk/home

A chlamydia screening intervention developed by PHE increased general practice screening tests rates by 76% and chlamydia diagnoses by 40%.

Reflecting the encouraging findings delivered by this chlamydia screening intervention, PHE is now piloting the ‘3Cs & HIV Programme’ nationally to help improve sexual health provision and testing in general practice.

Support is now available to organisations that are considering or developing a Social Impact Bond (SIB). Last year the Cabinet Office launched the Social Outcomes Fund (https://www.gov.uk/social-impact-bonds#sources-of-funding-for-sib-projects) which offers a top up to outcomes payments for SIBs in complex areas. In July the Big Lottery Fund launched Commissioning Better Outcomes which will also offer top ups to outcomes payments in SIBs. Together these will make up to £60m of support available for SIBs tackling complex issues such as reoffending and drug addiction. To simplify the bidding process there will be a single application process for both funds details of which can be found here: http://www.biglotteryfund.org.uk/sioutcomesfunds.

In addition to this there is now support available for developers of SIBs at an earlier stage:

There is also now development funding for organisations developing SIBs which have passed the Expression of Interest stage of bidding to the joint Social Outcomes Fund / Commissioning Better Outcomes. The relevant application form can be requested here at our joint mailbox: sioutcomesfunds@biglotteryfund.org.uk.

In addition to this Bridges Ventures have set up a dedicated fund to invest in SIBs. More details can be found here: http://www.bridgesventures.com/bridges-social-impact-bond-fund. Big Society Capital is a cornerstone investor in this fund and has been active in SIB investment more generally so may also be a useful point of contact.